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R10.84
ICD-10-CM
General Abdominal Pain

Find information on general abdominal pain diagnosis, including clinical documentation, medical coding (ICD-10 R10.4, R10.9), differential diagnosis, and healthcare guidelines. Learn about symptoms, causes, and treatment options for abdominal pain, covering acute abdomen, chronic abdominal pain, and localized pain. Explore resources for physicians, nurses, and other healthcare professionals regarding proper documentation and billing for abdominal pain. This resource helps with accurate clinical evaluation and coding for generalized abdominal pain.

Also known as

Diffuse Abdominal Pain
Non-specific Abdominal Pain

Diagnosis Snapshot

Key Facts
  • Definition : Diffuse discomfort or soreness in the belly area, ranging in intensity.
  • Clinical Signs : Nausea, vomiting, bloating, diarrhea, constipation, loss of appetite, fever.
  • Common Settings : Emergency room, urgent care clinic, primary care office, telehealth.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC R10.84 Coding
R10.0-R10.9

Abdominal and pelvic pain

Generalized or localized pain in the abdomen or pelvis.

R10.4

Other generalized abdominal pain

Abdominal pain that is not localized.

K59.0-K59.9

Functional intestinal disorders

Disorders of intestinal function without structural abnormality, often with pain.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the abdominal pain localized?

  • Yes

    Where is the pain localized?

  • No

    Is the pain generalized?

Code Comparison

Related Codes Comparison

When to use each related code

Description
General Abdominal Pain
Localized Abdominal Pain
Functional Abdominal Pain

Documentation Best Practices

Documentation Checklist
  • General abdominal pain diagnosis documentation
  • ICD-10 R10.4, R10.9 abdominal pain unspecified site
  • Document pain onset, duration, character, location
  • Aggravating and alleviating factors must be noted
  • Associated symptoms (nausea, vomiting) documented

Coding and Audit Risks

Common Risks
  • Unspecified Pain Location

    Coding R10.4 (general abdominal pain) when documentation specifies location lacks specificity, risking underpayment and audit scrutiny. CDI can clarify.

  • Symptom vs. Diagnosis

    R10.4 may be coded inappropriately when a more specific diagnosis is documented, leading to inaccurate severity and HCC coding.

  • Lack of Supporting Documentation

    Insufficient documentation to support R10.4 makes it vulnerable to denials. Clear documentation of exam findings is crucial for compliance.

Mitigation Tips

Best Practices
  • Document precise location, character, radiation of pain for accurate ICD-10 coding.
  • Rule out life-threatening diagnoses for compliant billing and improved patient safety.
  • Query physician for unclear documentation to specify pain etiology for HCC coding.
  • Order appropriate diagnostic tests based on HPI for optimal E/M coding and CDI.
  • Correlate exam findings with symptoms for justified medical necessity and compliant billing.

Clinical Decision Support

Checklist
  • Verify location, quality, radiation of pain (ICD-10 R10.x)
  • Review history including medications, surgeries (SNOMED CT 75446002)
  • Assess vital signs, perform physical exam (patient safety)
  • Consider common causes appendicitis, obstruction (E/M coding guidelines)
  • Order appropriate labs, imaging if indicated (quality measures)

Reimbursement and Quality Metrics

Impact Summary
  • General Abdominal Pain: Coding accuracy impacts reimbursement for evaluation and management services.
  • Accurate diagnosis coding (R10.x) affects quality metrics for abdominal pain management and resource utilization.
  • Physician documentation detail influences correct severity coding and appropriate reimbursement levels.
  • Timely and specific coding of general abdominal pain improves hospital reporting accuracy and data analysis.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes for . Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Rule out life threats first
  • Document pain specifics
  • Consider R10.4 unspecified
  • Support with clinical findings
  • Check official coding guidelines

Documentation Templates

Patient presents with chief complaint of generalized abdominal pain.  Onset of pain reported as (gradual or sudden), duration (number) dayshoursweeks.  Pain quality described as (sharp, dull, aching, cramping, burning, gnawing).  Location of pain is diffuse and not localized to any specific quadrant.  Pain severity is (mild, moderate, severe) on a scale of 0-10, currently rated at (number).  Associated symptoms may include nausea, vomiting, diarrhea, constipation, bloating, flatulence, anorexia, fever, chills, weight loss, or fatigue.  Patient denies any hematemesis, melena, hematochezia, or dysuria.  Medical history significant for (list relevant medical conditions).  Surgical history includes (list surgeries).  Current medications include (list medications).  Allergies include (list allergies).  Family history notable for (list relevant family history).  Social history includes (tobacco use, alcohol use, drug use).  Physical examination reveals (abdomen soft or rigid, bowel sounds present or absent, tenderness to palpation, rebound tenderness, guarding, or distension).  Vital signs stable with heart rate (number) bpm, blood pressure (number)/(number) mmHg, respiratory rate (number) breaths per minute, and temperature (number) degrees Fahrenheit.  Differential diagnosis includes gastroenteritis, irritable bowel syndrome, constipation, intestinal obstruction, mesenteric ischemia, appendicitis, diverticulitis, cholecystitis, pancreatitis, urinary tract infection, pelvic inflammatory disease, or other intra-abdominal pathology.  Ordered complete blood count, comprehensive metabolic panel, urinalysis, and abdominal imaging (X-ray, CT scan, ultrasound) to further evaluate.  Patient advised on symptomatic management with pain medication, antiemetics, and hydration.  Return precautions discussed.  Follow-up scheduled.
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